2011 Voter registration form APPROVED - azsos.gov

1 ARIZONA Voter registration FORMFORMULARIO DE INSCRIPCI N DE VOTANTE EN ARIZONALAS INSTRUCCIONES EN ESPA OL SE ENCUENTRAN AL REVERSO<Fold Line-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Fold Line>*USE BLACK PEN ~ COMPLETELY FILL OUT form *USE PLUMA DE TINTA NEGRA ~ LLENE EL FORMULARIO COMPLETAMENTE<Remove tape and fold to mail ------------------------------------------------------------------------------------------------------------------------------------------------------Remove tape and fold to mail>Questions?

2 For questions regarding Voter registration , call your County Recorder listed on the back of the formYou Can Use This form To: Register to vote in the state of Arizona Let us know that your name, address or party affiliation has changedTo Register To Vote In Arizona You Must (Qualifications): Be a United States citizen (see citizenship requirements on back) Be a resident of Arizona and the county listed on your registration Be 18 years of age or more on or before the day of the next regular General ElectionWARNING: Executing a false registration is a class 6 felonyYou Cannot Register To Vote In Arizona If: You have been convicted of a felony and have not yet had your civil rights restored You have been adjudicated incompetentHow To Register To Vote.

3 To be eligible for an election, you must register to vote at least 29 days before the election You can mail or hand deliver your completed form to your County Recorder s office If by mail, the form must be received by the County Recorder no later than 5 days afterthe last day to register to vote in that election or be postmarked 29 days or more beforean election and received by the County Recorder by 7 on election day Your County Recorder s office will mail you a proof of registration within 4 6 weeks You can register online at With Disabilities May: Contact the County Recorder/Elections Department for information about early voting,accessible voting, or other OF CITIZENSHIP REQUIREMENTA complete Voter registration form must containproof of citizenship or the form will be rejected.

4 Ifyou have an Arizona driver license or nonoperat-ing identification license issued after October 1,1996, this will serve as proof of citizenship. If not,you must enclose proof of citizenship with theform. Please refer to the back of the form for a listof acceptable documents to establish your citi-zenship. PERMANENT EARLY VOTING LIST EARLY BALLOT VOTE BY MAILAny Voter may request to be included on the Permanent Early Voting List (PEVL) in order toautomatically receive an early ballot for all elec-tions he or she is eligible to participate. To be onthe list, the address where you receive mailmust be in Arizona.

5 Military and overseas votersare also eligible to be on the PEVL using theiroverseas mailing address. To automaticallyreceive an early ballot, mark Yes in box "Yes" is marked in box 1, you will be added to thePEVL. If "no" is marked in box 1, your name will notbe added to the PEVL and will be removed fromPEVL if it was previously included on the list. If nei-ther "Yes" or "No" are marked in box 1, your recordwill remain unchanged as it relates to being on thePEVL.[1] Permanent Early Voting List Early Ballot (see instructions above) YES, I want to automatically receive an early ballot for each election for which I am eligible.

6 NO, I DO NOT want to automatically receive an early ballot. I understand CHECKING THIS BOX will remove my name from the list if it was previously included. BOX FOR OFFICE USE ONLYS[2] Last NameFirst NameMiddle [3] Address where you live If no street address, describe residence location using mileage, cross streets, parcel #, subdivision name and lot, or landmarks. Do not use post office box or business address. Draw a map below if located in rural area.[4] [5] City[6] Zip[7] Address where you get your mail, if mail is not delivered to your home[8] Last four digits of Social Security Number[9] AZ Driver License Number or AZ Nonoperating License Number[10] Optional Tribal Identification Number[11] Alien registration Number[12] Birth Date (MM/DD/YYYY) [13] State or Country of Birth[14] Party Preference Republican Democratic Other _____[15] Telephone Number[16] Occupation[17] If you were registered to vote in another state, list former address including county and state[18] List former name (if applicable)

7 [19] Father s name or mother s maiden name[20] Are you willing to work at a polling place on election day? Yes No[21] E-mail address[23] If no street address draw a map here: [22] Are you a citizen of the United States of America? Yes No Will you be 18 years of age on or before election day? Yes NoVOTER DECLARATION By signing below, I swear or affirm that the above information is true, that I am a RESIDENT of Arizona, I am NOT a convicted FELON or my civil rights are restored, and I have NOT been adjudicated HEREDATE[24] If you are unable to sign the form , the form can be completed at your direction.

8 The person who assisted you must sign here. _____SIGNATURE OF PERSON ASSISTINGDATE EWNSIf you checked No to either one of these questions, do not submit this Voter registration form (Translation)FORMULARIO DE INSCRIPCI N DE VOTANTE EN ARIZONA Preguntas? Para preguntas con respecto a la inscripci n de votante, llame a su Registrador del Condado indicado al reverso del formularioUsted puede usar este formulario para: Inscribirse para votar en Arizona Informarnos que su nombre, direcci n o afiliaci n de partido ha cambiado Para inscribirse para votar en Arizona, usted tiene que (Requisitos).

9 Ser ciudadano de los Estados Unidos (vea los requisitos de la prueba de ciudadan a en el reverso) Ser residente de Arizona y del condado indicado en su inscripci n Tener 18 a os de edad m s en antes del d a de la pr xima Elecci n General normalADVERTENCIA: El ejecutar una inscripci n falsa es un delito grave clase 6 Usted no puede inscribirse para votar en Arizona si: Usted ha sido condenado por un delito grave y todav a no se le han restituido susderechos civiles Usted ha sido juzgado incompetenteC mo inscribirse para votar: Para ser elegible para una elecci n, usted se debe registrar para votar por lo menos 29d as antes de la elecci n Usted puede enviar por correo su formulario llenado a la oficina de su Registrador delCondado o entregarlo personalmente Si se env a por correo, la forma debe ser recibida por el Registrador del Condado nom s tarde de 5 d as despu s del ltimo d a para registrarse para votar en esa elecci n contar con un sello postal fechado 29 d as m s antes de una elecci n y ser recibidopor el Registrador del Condado antes de las 7 del d a de la elecci n.

10 La oficina del Registrador de su Condado le enviar un comprobante de registro dentrode 4 a 6 semanas Usted puede registrarse en l nea en ciudadanos con discapacidades pueden: Comunicarse con el Registrador del Condado/Departamento Electoral para informaci nsobre la votaci n temprana o cualquier adaptaci n para votarREQUERIMIENTO DE COMPROBANTE DE CIUDADAN AUna forma completa de registro electoral debecontener comprobante de ciudadan a o dichaforma ser rechazada. Si usted tiene una licenciade manejo o identificaci n no operativa de Arizonaemitida despu s del 1 de octubre de 1996, staservir como comprobante de ciudadan a.